Sunbed Regulation: A Review of Practice in the South West Executive Summary
Sunbed Regulation: A Review of Practice in the South West Executive Summary Authors: Nicola Bowtell 1, Veronique Poirier 1, Sharon Smith 2, Jenny Morris 2 and Julia Verne 1 1 South West Public Health Observatory 2 Chartered Institute of Environmental Health Publication Date: January 2010 Cancer Intelligence Service, South West Public Health Observatory Grosvenor House 149 Whiteladies Road Bristol BS8 2RA Tel: 0117 970 6474 General enquiries: info@swpho.nhs.uk Website address: www.swpho.nhs.uk/skincancerhub
Executive summary Aims The research was commissioned by Cancer Research UK to follow up on a national study of sunbed outlet variation and deprivation and: provide a more detailed survey of sunbed locations in the South West region; investigate the Local Authority policies towards the regulation of sunbed salons; investigate issues of compliance with current guidance and legislation across the sunbed industry; undertake a feasibility study for any future national projects; and demonstrate the data that can practically be collected on sunbed salon distribution and local policies toward their regulation. Methodology The information for this study was gathered using a multi-method, three-stage approach. This allowed an in-depth exploration of the complex issues involved in this study. Fieldwork took place from March to May 2009 and involved: Stage 1 desktop research; Stage 2 a web-based survey; and Stage 3 qualitative in-depth telephone interviews. Stage 1: Desktop research Existing policy and guidance on the regulation of the sunbed industry was analysed. This included consideration of the following documentation: legislation and guidance on sunbeds (national and international); inspection protocols; sunbed audits; research on compliance with guidance on legislation of the sunbed industry. Stage 2: Web survey The web survey on compliance with guidance on legislation of the sunbed industry was designed by the South West Public Health Observatory (SWPHO) with assistance from the Chartered Institute of Environmental Health (CIEH). The questionnaire contained a range of topics covered in five main sections: Local Authority awareness of sunbed operators within their area; Page 1
policies and procedures for inspections and other interventions; views on guidance and support for inspections of sunbed outlets; policies on skin cancer prevention; contact details and policy checklist. The questionnaire was designed to capture data from Health and Safety and/or Environmental Health Departments located in Local Authorities across the South West region. The questionnaire was kept as brief and simple as possible to maximise response rates. It took approximately 10 minutes to complete, and included mostly pre-coded questions. SurveyMonkey, an online survey tool, was used both to design the questionnaire and collate the responses. This web questionnaire allowed for rapid and costeffective collation of this data. A number of approaches were used to maximise response rates. Firstly, a small news item was included in the CIEH newsletter one week prior to distribution. Secondly, the CIEH circulated the questionnaire, with two reminders sent prior to the deadline. Finally, a telephone mop-up exercise was undertaken with Local Authorities who had not already completed the survey. A combination of all the methods discussed here ensured that 39 (86%) of the 45 Local Authorities in the South West responded. Stage 3: Qualitative follow-up The aim of this stage was to undertake a rich and detailed exploration of some of the key findings emerging from Stages one and two. In-depth interviews were undertaken with Local Authorities and professional bodies. The following issues were explored during these interviews: a local picture of current sunbed outlets; sunbed mapping and audit approaches; work prioritisation setting and the inspection of sunbed outlets; complaints regarding sunbed outlets; broader policy and practice issues regarding sunbeds; the feasibility of establishing a national database; the need for future guidance. A sampling frame was developed to ensure the appropriate mixture of the following characteristics: urban versus rural; high density sunbed areas versus low density sunbed areas; and high level sunbed activity in Local Authorities versus low level sunbed activity. A sample was selected after analysing data collated at Stage 2. This final stage of the research process helped develop and refine a typological assessment of sunbed policy and the execution of this policy across Local Authorities in the South West of England. Figure 1.2: Summary: research methods Stage 1 Desktop research Stage 2 Web survey Stage 3 Qualitative depth Page 2
Number and types of sunbed outlets 378 sunbed outlets were recorded by 31 Local Authorities in the South West region. North Cornwall recorded the highest number of sunbed outlets (75). Four other Local Authorities had high sunbed volumes (30 or more) Torbay, Taunton Deane, Mendip and the City of Bristol. Local Authorities recorded sunbed outlets in a variety of settings: beauty salons (34, 89.5%); sunbed only outlets (27, 71.1%); hairdressers (24, 63.2%); leisure centres (20, 52.6%). (N=38 Local Authorities) A small number of Local Authorities had sunbed outlets located in more unusual settings: carpet shops; travel agents; cosmetic piercing premises; amusement arcades; pubs; betting shops; and a lap-dancing bar. Supervision and sunbed outlets Unsupervised outlets and part-supervised outlets are of most public health concern due to the low level of public health advice and supervision provided for customers. In the South West 31% of sunbed outlets were part-supervised and 20% unsupervised (N=34 Local Authorities). Unsupervised hot spots, i.e. where there were 10 or more unsupervised outlets, were identified in Bournemouth, Restormel, North Cornwall and Bristol. Areas with medium volume (4 9 outlets) were identified in South Gloucestershire, Salisbury and Mendip. Unsupervised outlets presented numerous problems including: weaker monitoring procedures allowing customers unlimited access; lack of public health advice; easy use by under-18s; and unsatisfactory emergency procedures for customers in distress. Part-supervised outlets (in particular sunbeds located in hairdressing outlets) are also of public health concern. A combination of inadequate staff training (in particular hairdressers and other more unusual sunbed outlet settings), patchy public health advice and a limited monitoring system raise concerns. Indeed, some environmental health officers observed that practice within these outlets can at times be no different to that provided by unsupervised outlets. Local Authorities and sunbeds Although the numbers are declining, just under a quarter (9/37) Local Authorities still had at least one sunbed located on their premises. (N=37 Local Authorities). Half (10/20 sunbed outlets) of Local Authority sunbed outlets were fully supervised, 9 were part-supervised and one Local Authority sunbed outlet was unsupervised. (N=20 Local Authority sunbed outlets) Page 3
Inspections The Sunbed (Regulation) Act was passed in April 2010 and will come into force in April 2011. New inspection procedures will be outlined as part of this process. However, whilst this research was undertaken, England, Wales and Northern Ireland did not have specific national legislation aimed at controlling the cosmetic use of sunbeds. There was generic health and safety legislation and specific guidance that applied to sunbed outlets. Inspection rates of sunbed outlets by Local Authorities in the South West were low in 2008. Indeed, nearly half of those Local Authorities surveyed did not carry out any inspections during this time. (N=33 Local Authorities) Roughly one half of 33 Local Authorities (17) inspected private outlets every 13 36 months, and the other (16) every 3 years or more (N=33 Local Authorities). Most Local Authorities that had not carried out inspections in 2008 reported that this was primarily due to the low priority setting of this work by Government guidance. Low staffing levels in some Local Authorities tended to compound this problem. Almost a quarter of Local Authorities (5/23) carrying out inspections in 2008 identified at least one outlet not meeting expected standards (N=23 Local Authorities). The most frequently mentioned concern identified by Local Authorities was the quality of public health advice provided to customers prior to using this equipment. Other concerns included: unsupervised equipment (13, 50%); inadequate customer advice (12); inadequate maintenance of equipment (8); and the inadequate use of consent forms (8). (N=26 Local Authorities) The majority of Local Authorities identified a clear need to update current guidance for the inspection of sunbed outlets. Environmental health officers suggestions for change fell into three key areas of improvement: more up-to-date information on both public health and technical information for inspectors; more user-friendly inspection guidance; and more up-to-date skin cancer prevention materials (customer leaflets and posters and a pamphlet for sunbed operators). Just over one third of Local Authorities surveyed felt inspections should be given a higher work priority (N=34 Local Authorities). The majority (20/35) of Local Authorities would welcome the introduction of the mandatory licensing of sunbed outlets. (N=35 Local Authorities) Complaints Approximately one fifth (6/34) of Local Authorities received at least one complaint regarding a sunbed outlet during 2008 (N=34 Local Authorities). The main complaints received by Local Authorities in the South West region were as follows: cleanliness and hygiene issues; burns; underage use of sunbeds; and faulty equipment (N=20 Local Authorities). Page 4
It was felt that complaints received by Local Authorities tend to be the tip of the iceberg. This under-reporting was thought to be linked to both a low public awareness of complaints procedures and the responsibilities of sunbed outlet owners. Wider skin cancer prevention initiatives The Health Education Authority published guidance on producing skin cancer prevention policies for Local Authorities (Health Education Authority, 1998) more than 10 years ago. Just over one tenth (4/35) of Local Authorities surveyed have a skin cancer prevention policy and only one Local Authority was thinking of developing one (N=35 Local Authorities) No Local Authorities had carried out a risk awareness campaign with sunbed users. Local Authorities were asked what new materials and resources would help them in their skin cancer prevention work. Of the 23 Local Authorities that responded, improvements mentioned were as follows: more detailed public health information (19); more up-to-date health and safety information on equipment (15); a training pack for sunbed operators (17); guidance on wider skin cancer prevention policies (9); and guidance on delivering skin cancer prevention campaigns (7). (N=23 Local Authorities) Mapping sunbed outlets Very few Local Authorities have licensing in place across the UK. Indeed none of the Local Authorities that responded to our survey had developed licensing of sunbed outlets within their Local Authority. Where licensing does exist, Local Authorities can create registers of the number and locations of commercial outlets in their area. Comprehensive information on sunbed outlets is not routinely collated across Local Authorities due to the absence of a national registration scheme. The quality of data held by Local Authorities on the sunbed outlets in their area is at best out of date and at worst an extremely poor indicator of the level of local sunbed provision. Just over one third (14/37) of Local Authorities in the South West had undertaken a mapping exercise (counting and describing their sunbed outlets). There is no guidance on sunbed mapping approaches, and methods adopted by Local Authorities vary widely. The way that data on sunbed outlets is held electronically varies between Local Authorities, with different data fields and different IT systems. Page 5
Summary of main findings Inspections The inspection of sunbed outlets is not a high or even medium work priority for Local Authorities, who generally take their steer from Government guidance and targets. The frequency of inspections for sunbed outlets reflected this and was extremely infrequent. Where inspection activity occurs, a significant number of environmental health officers have observed poor practices, but do not have legislative powers to effectively deal with these. Environmental health officers identified a need for additional information and guidance to improve the quality of inspections. The audit and mapping of sunbed outlets This is a low work priority and the extremely low levels of audit and mapping work undertaken by Local Authorities reflected this. There is a wide variety of methods used by Local Authorities to collect information on sunbed outlets. Information is not routinely updated on computer systems. The information held is out of date and incomplete. Data is held locally but not nationally. Databases are not compatible and hold varied data fields. Complaints Complaints could prove a good indicator of poor compliance across the sunbed industry, however there is a low level of recording of complaints at present. The general public is ill-informed of complaints procedures and recommended standards. There are limited if any sanctions available to officers to address complaints and non-compliance. Evidence of system failure and public health risk The worst examples of poor practice were observed in unsupervised and partsupervised outlets. These included poor public health information, customer monitoring, record keeping and usage by under-16s. Unsupervised outlets would be unable to respond swiftly if an emergency arose. Equipment is not always maintained to a satisfactory level in all outlet types. Information on cases/incidents of poor practice is not routinely collated on a national level. Wider skin cancer prevention campaigns Very few Local Authorities have a skin cancer prevention policy, and skin cancer prevention work is rarely undertaken by Local Authorities. There is a need for skin cancer awareness and prevention materials tailored to Local Authorities needs, coupled with guidance on running prevention campaigns. Page 6
Recommendations Regulation All sunbed outlets should be registered and licensed. This would allow effective controls and regular checks on adherence to standards. It would also allow the monitoring of trends, distribution of commercial outlets and machine types. The inspection of sunbed outlets needs to move up the current health and safety, environmental health and public health agendas to assist in raising the profile of sunbed work within Local Authorities. Detailed information on the health risks associated with the use of sunbeds must be provided to users and should be clearly visible on machines. The use of sunbeds by at-risk groups should be discouraged. Regular inspection of sunbed outlets is vital to ensure compliance with legislation and guidance. Local Authorities should be provided with adequate sanctioning powers. A systematic review of all inspection tools and guidance currently being used by environmental health officers needs to be carried out urgently. Building on current good practice, a new set of inspection tools and accompanying guidance should be drawn up by key stakeholders. This should ensure new standardised and efficient sunbed inspection practice across the UK. The auditing and mapping of sunbed outlets The auditing of sunbed outlets needs to be given a higher priority by Local Authorities, and work should be undertaken more frequently to recognise the public health risks posed and the high rate of outlet turnover in the industry. Methods currently used by Local Authorities in their mapping and auditing work need to be standardised. Guidance or a toolkit should be produced documenting best practice in this field. The data collected by environmental health officers on sunbed outlets needs to be standardised across all Local Authorities, kept up-to-date, collated and analysed nationally, and preferably held on one national database. Licensing requirements Unsupervised outlets should be banned. This report highlights evidence of poor public health advice, inefficient control systems to ensure customers safe use of these devices and, importantly, evidence that establishments were being used by young people (under-18s). Training should be provided for all sunbed operators, starting with partsupervised outlets where sunbeds are offered as a minor part of the overall business operation (for example, hairdressers). This should Page 7
focus on public health information, the operation and maintenance of equipment, monitoring and advising potential customers on sunbed use and maintaining customer records. Evidence of public health/health and safety system failures should be reported locally and made more widely available through a national surveillance system. A section addressing sunbed outlets operating on Local Authority premises should be included in any future legislation. A clear date should be set for the phasing out of all Local Authority sunbed outlets, with Local Authorities being highlighted as role models for good practice. Complaints The general public should be given information on examples of poor sunbed practice. In addition, they should be well-informed of the complaints procedures so they can report these whenever they come across them. All complaints relating to sunbed outlets should be held at both local and national level, enabling the monitoring of trends, and ensuring a timely response to poor practice. Officers need more powers of enforcement coupled with improved resources, to ensure they are best able to respond to complaints. Future intelligence: data collection and a national database Developing a national database on sunbed outlets would have to take into account the following issues: data entry procedures; processes used to collect data; a standard set of data fields; a review of IT across Local Authorities; funding; and where and how the database would be hosted and managed. Wider sunbed and skin cancer prevention campaigns Local Authorities would welcome guidance on developing and delivering a local skin cancer prevention policy. New skin cancer prevention materials (including those for sunbeds) should be developed and tailored to the needs of Local Authorities. Skin cancer prevention campaigns should be given a higher priority and appropriate funding structures established to support these campaigns. In addition, these campaigns should be placed within the public health priority framework. Page 8
Further information The full report, Sunbed Regulation: A Review of Practice in the South West, is available from the South West Public Health Observatory s Skin Cancer Hub website, http://www.swpho.nhs.uk/skincancerhub About the South West Public Health Observatory The South West Public Health Observatory (SWPHO) is part of a network of regional public health observatories in the UK and Ireland. These were established in 2000 as outlined in the Government White Paper Saving lives: our healthier nation. Key tasks include: monitoring health and disease trends; identifying gaps in health information; advising on methods for health and health impact assessment; drawing together information from different sources; and carrying out projects on particular health issues. The SWPHO incorporates the National Drug Treatment Monitoring System South West (NDTMS-SW), and in April 2005 merged with the South West Cancer Intelligence Service (SWCIS). The SWPHO works in partnership with a wide range of agencies, networks and organisations regionally and nationally to provide a seamless public health intelligence service for the South West. The SWPHO is the lead cancer registry for skin cancer in England and developed the Skin Cancer Hub website as a resource to support the early diagnosis and prevention of skin cancer. For more information about the SWPHO and its partner organisations, please visit www.swpho.nhs.uk.